| The following vignette applies to the next 3 items. |
A 25-year-old man comes to the emergency department with pain in his right hand and wrist. A few hours earlier, he fell forward and landed on his outstretched right hand while playing football. He could not continue playing due to intolerable pain. The patient has no other medical problems and does not use tobacco, alcohol, or illicit drugs. Examination shows mild swelling in the dorsum of the right hand with preserved range of motion. Right hand grip strength is reduced. There is severe tenderness on palpation of the radial dorsal aspect of the wrist.
Item 1 of 3
Which of the following is the most likely diagnosis?
This patient fell onto his outstretched hand and has acute pain at the wrist and tenderness at the anatomic snuffbox. These are clinical features concerning for a scaphoid fracture, which is the most common carpal bone fracture and is typically caused by forceful dorsiflexion at the wrist. The scaphoid can be forced against the dorsal part of the distal radius, creating a fulcrum for injury. Patients can have swelling, decreased grip strength, pain and tenderness at the radial aspect of the wrist in the anatomic snuffbox, and minimally decreased range of motion (unless dislocated fracture is present).
The next step in management would be to confirm the diagnosis with x-rays of the wrist in full pronation and ulnar deviation to better expose the scaphoid. Initial x-rays can be negative if the fracture is compressed or minimally displaced.
(Choice A) A Colles fracture is another common fracture caused by falling onto an outstretched hand. It is a dorsally angulated or displaced distal radius fracture that is typically associated with visible angulation proximal to the wrist joint ("dinner fork deformity"). Lateral radiographs can confirm Colles fracture diagnosis.
(Choice B) A hamate fracture can occur while falling onto an outstretched hand, usually near the hook of the hamate (hamulus) containing the ulnar artery and nerve. Pain and swelling of a hamate fracture occur in the hypothenar eminence and ulnar aspect of the wrist; however, this patient's pain is in the radial aspect.
(Choice C) A radial styloid fracture (Hutchinson or chauffeur fracture) typically occurs due to a direct blow to the styloid while falling onto an outstretched hand with ulnar deviation and supination; this results in a fracture dislocation of the radial styloid and either the lunate or scaphoid. It is significantly less common than scaphoid fracture.
(Choice E) A sprain of the wrist ligaments is typically associated with mild pain or stiffness with normal range of motion and resolves with conservative and supportive care. A wrist sprain typically causes pain that worsens with flexion and extension of the ligaments. Instead, this patient has severe point tenderness with palpation.
Educational objective:
Scaphoid fracture is the most common carpal bone fracture, and commonly occurs due to falling onto an outstretched hand with a dorsiflexed wrist. Findings include decreased grip strength, decreased range of motion in the wrist, and tenderness to palpation of the scaphoid within the anatomic snuffbox.